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7.4 Crying baby

My baby cries a lot. What should I do?

Babies cry to express a need, and the cry of the baby causes the parent to respond.

Breastfeeding is often the first thing that is blamed when the baby is perceived to have problems. Babies who cry frequently are at higher risk of being given foods and drinks inappropriately 1 or a pacifier/dummy and infants who are perceived as 'fussy' are more likely to be fed solid foods before 4 months. 2

Using counseling skills techniques, listen to what the mother is saying, and try to determine a cause. Observe her interaction with her baby and what settling techniques she is using. Watch the baby breastfeeding and examine the baby. If necessary, refer to a doctor for further assessment.

Build the mother's confidence

  • Listen and accept the mother's feelings
  • Reinforce what the mother and baby are doing right; what is normal
  • Give information relevant to this mother
  • Give practical help

Some suggestions that may help

  • Hold her baby skin-to-skin against her chest; her warmth, smell and heartbeat will help to soothe him.
  • Offer her breast to her baby: he may be hungry, thirsty or in need of suckling for a sense of security; some babies will settle quickly when offered a 'nearly-empty' breast when not hungry.
  • Attend to baby's comfort: change nappy/diaper; check baby is not too warm not too cold; etc
  • Talk to, sing, rock the baby while holding close. Gently swinging the baby sideways (ie from ear to ear) helps settle quicker than backwards and forwards movement.
  • Stroking or baby massage with oil may help.
  • Involve the mother's support people in the discussion so they understand that supplements aren't the solution to this problem.
  • Suggest use of a baby sling/pouch for the mother to be able to continue other tasks or ask that someone else carry and comfort the baby for some time, giving the mother a break.
  • Encourage the involvement in a mother-to-mother support group for the mother to share experiences and concerns.
  • Investigate the mother's intake of caffeinated drinks and smoking - both of which are associated with crying and unsettled babies.
  • Suggest a 24-48 hr diary of the infant's behaviour - this may help you determine a link to a time of day or activity and help the mother's perception of the crying.

To Swaddle or not to swaddle?

A crying baby needs comfort and reassurance - do you like to be ignored when you are upset?
Some cultures use swaddling methods and this practice has disseminated into many modern parenting styles. The adult observes that the infant becomes calm, quiet and less likely to disturb themselves with jerky movements.
  • Swaddling increases intrathoracic pressure which, in turn, decreases pulmonary functional residual capacity. 3
  • It also decreases spontaneous cortical arousals and autonomic control in newly swaddled sleeping infants - similar responses are observed in victims of sudden infant death. 4

Be cautious not to look for a quick fix. A 'good' baby is not a sleeping baby. Be a detective to help determine the existence of an underlying organic cause of the unsettled behaviour and reassure the mother.

Some babies may benefit from gentle swaddling. Carefully explain the correct application of this technique to ensure it isn't used as a first method of settling or used inappropriately.

Be alert!

A crying baby causes strong emotional responses in people so be alert to the mother's state of mind and ability to cope. This may be a desperate plea for more professional help, not just settling tips.

Pacifiers/Dummies

Baby Friendly Step 9 and Point 4

Step 9 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
Point 4:
Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, Canada, New Zealand

Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia

Step 9: Give no artificial nipples/teats or dummies/pacifiers to breastfeeding infants.

Sucking and breastfeeding

  • The suckling technique used during breastfeeding is completely different to the action of sucking used on a bottle teat or non-nutritive sucking on a pacifier/dummy.
    Babies are thought to 'imprint' latching and suckling skills from their earliest experiences.5 When artificial teats/dummies are their predominant feeding experience, learning to latch and use a correct sucking technique is difficult.

  • Pacifiers/dummies stifle early feeding cues and are often used to delay breastfeeding and reduce the time spent at the breast. This will have a significant impact on the control of milk synthesis and potential to decrease milk supply.
    Studies of full term newborns and preterm infants demonstrate reduced duration of exclusive breastfeeding when pacifiers are used extensively and/or more than a few supplements are given using bottles.6,7

  • Teats and pacifiers are reservoirs for infection which adheres easily to the surface.8,9
  • Pacifiers are associated with an increase in otitis media and dental malocclusion.

  • Some studies recommend the use of pacifiers for the prevention of sudden infant death syndrome (SIDS).10 The explanation offered, that an infant sucking on a pacifier during the night has more spontaneous arousals, has been shown not to occur.11 However, breastfeeding and co-sleeping have been shown to reduce the risk of SIDS, and pacifier use reduces the incidence of breastfeeding.

Should a mother wish to use a pacifier it's use should be guided by ...

  • do not commence use until breastfeeding well established, eg 4 - 6 weeks or longer
  • only use it at the time the infant is put down to sleep - if rejected by infant do not force
  • when the pacifier falls out during the infant's sleep it is not to be reinserted.

When crying is excessive

The most common causes of excessive crying are

  • immaturity in the first 7-8 weeks of life
  • lactose malabsorption,
  • colic, and
  • gastroesophageal reflux disease

Lactose malabsorption/overload

This is primarily a condition of overload of large volumes of breastmilk in the gut which exceeds the ability of lactase to split it. Undigested lactose osmotically draws in fluid from the abdominal cavity where it ferments in the presence of the gut bacteria.

Presentation

Onset is usually in the first few weeks of life, but could present later if mother changes her feeding style.

  • Baby
    • usually thriving baby, putting on weight very well
    • frequently distressed and has inconsolable crying
    • short sleeps followed by waking in pain
    • frequently sucking fist for comfort
    • draws knees up to chest while crying
    • flatulence ++
    • many nappies/diapers per day soaked with clear urine
    • frequent, watery, copious, green-ish and/or frothy stools
  • Mother
    • has a copious breastmilk supply and a large breastmilk storage capacity
    • offers baby both breasts at most breastfeeds, taking baby off first breast after a measured amount of time, rather than when it feels 'drained'
    • may feel the baby's 'fist sucking' indicates hunger and breastfeeds baby again; usually from breast not (or least) suckled at the previous feed
    • may feel she has an inadequate supply because of his frequent feeding and crying
    • may be concerned baby has a gastrointestinal infection because of the unusual stool appearance

Management

  • Reassure mother of the volume and suitability of her breastmilk for her baby.
  • Discuss with her the signs that indicate the infant is in good health.
  • Encourage breastfeeding from only one breast over a period of time, determined individually. eg. One mother may repeatedly breastfeed from only her left breast for a 2-4 hours time period. Every time baby indicates a need to suckle during that time he will be put to the left breast and receive breastmilk that has an increasing fat content as that breast is progressively drained. This will slow the gastric emptying, and usually the infant will take less breastmilk when the breast is less full; both factors resulting in less lactose being transferred rapidly into the small intestine. For the next 2-4 hour block of time, the infant may only feed from the right breast, and so on until the problem is resolved. Mothers will be able to determine by trial and error the most appropriate time period for each breast.
  • Frequency of breastfeeding is not restricted. All feeding cues during the set time period are responded to with the same breast.
  • Care of the breast not being suckled may involve gentle expressing or releasing enough milk for comfort and applying ice packs to prevent engorgement. This can be done while the infant is feeding on the other breast.
  • Resolution of the infant's symptoms is usually rapid - within 48 hours, although it could take up to a week.
  • A return to two-sided breastfeeding may be indicated in time as milk volume settles and gut maturity improves, either for most feeds or perhaps only evening feeds.

Workbook Activity 7.7

Complete Activity 7.7 in your workbook.

Colic

One study12 noted that infants who have colic cry excessively without an identifiable need. They are difficult to console and provoke much parental anxiety. Sleep is interrupted for both infant and caregiver, and mothers experience increased risks of breastfeeding failure, postpartum depression, and marital conflict. When infants cry excessively, they are at a much greater risk of child abuse. Parents become desperate for resolution and accept advice and therapies from a wide variety of resources. The authors estimate that between 16% and 26% of all infants experience colic.

Reviews of the research13,14 examining pharmaceutical, naturopathic and behavioral techniques for their effectiveness in reducing colic are only able to recommend a low-allergen maternal diet as having any effect on the breastfed baby. Only one pharmaceutical agent (dicyclomine) was found to be any more effective than a placebo, and due to serious side effects it is no longer recommended.

A tea containing camomile and other herbs had a degree of effectiveness, however the volume required to be given to the infant to obtain this effect was excessive and therefore not recommended.

A pilot study15 found a significant decrease in crying and increase in sleeping in colicky infants receiving cranial osteopathic manipulation. Larger studies are required to confirm the effectiveness of this intervention.

Eglash13 considers pure colic to be a patterned daily behavior of crying that a parent can predict will occur and stop at certain times, and the baby is fine at other times of day. This health care provider does not expect a change in maternal diet to help, the condition being self-limiting by about age 3 months.

Management

  1. Refer for medical review to exclude pathology
  2. Low-allergen diet for the mother may result in some improvement
  3. Infant and parent support measures

Gastroesophageal Reflux

Gastroesophageal reflux occurs when stomach contents reflux into the esophagus/oesophagus and out the mouth, resulting in regurgitation, or spitting up, and vomiting. This condition is very common and is caused by the sphincter at the top of the infant's stomach having not yet become efficient at retaining the stomach contents. Most babies with this condition are happy and continue to thrive, outgrowing the worst of it around 6 months of age.

Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease (GERD, GORD) occurs when the constant refluxing of stomach contents causes burning and ulceration of the esophagus and sometimes aspirates into the lungs. This medical condition will be diagnosed and treated by the infant's doctor.

Breastfeeding Management

  • Breastfeed the infant in an upright position, at least 30o elevation of the head above the stomach.
  • Some babies will want to breastfeed very frequently, as the breastmilk eases the pain by neutralizing stomach acid.
  • Cow milk protein allergy is frequently associated with GERD. A trial of maternal low-allergen diet is recommended.16

What should I remember?

  • Crying is an expression of a need.
  • Some practical suggestions to settle the infant's crying.
  • The possible underlying causes of excessive crying.
  • The breastfeeding management strategies which may assist lactose overload symptoms.
  • Excessive crying not relieved by practical suggestions is a marker requiring medical review.

Self test quiz

Notes

  1. # Karacam Z (2007) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women
  2. # Wasser H et al. (2011) Infants perceived as fussy are more likely to receive complementary foods before 4 months.
  3. # Thach BT (2009) Does swaddling decrease or increase the risk for sudden infant death syndrome?
  4. # Richardson HL et al. (2010) Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants.
  5. # Woolridge MW (1986) The 'anatomy' of infant sucking.
  6. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  7. # Collins CT et al. (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial
  8. # Comina E et al. (2006) Pacifiers: a microbial reservoir
  9. # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
  10. # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
  11. # Hanzer M et al. (2009) Pacifier use does not alter the frequency or duration of spontaneous arousals in sleeping infants.
  12. # Fireman L et al. (2006) Colic
  13. # Crotteau CA et al. (2006) Clinical inquiries. What is the best treatment for infants with colic?
  14. # Garrison MM et al. (2000) A Systematic Review of Treatments for Infant Colic
  15. # Hayden C et al. (2006) A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic
  16. # Heine RG (2006) Gastroesophageal reflux disease, colic and constipation in infants with food allergy